Impact of a digital training platform and tailored education on the chest image interpretation performance of healthcare professionals.

INTRODUCTION: With the use of expert consensus a digital training tool was developed which proved useful when teaching radiographers how to interpret chest images. The training tool included A) a search strategy and B) an educational video programme to communicate the search strategies using eye tracking technology. METHODS: A multi-reader multi-case study was undertaken to assess the effectiveness of a training tool and study day. The interventions were designed to cover a range of potential pathological presentations. Participants, physiotherapists and nurse practitioners working at a cardiothoracic Intensive Care Unit (ICU), were asked to interpret 20 chest images at the beginning of the study and following access to each intervention. Participants received access to the training tool at different times for a period of 4-6 weeks. A study day was then be provided to all participants and interpretations of a different dataset were completed by all. Each participant was asked to complete a questionnaire to gain perceptions of the training provided. RESULTS: Twenty-eight participants interpreted a total of 1680 chest radiographs. Improvements in specificity were noted across the participants. Sensitivity fell in both groups following both training interventions. CONCLUSION: Face to face learning and digital components are potentially useful in professional development and revision in chest x-ray interpretation for non-medical healthcare professionals working in an ICU setting. IMPLICATIONS FOR PRACTICE: The training tool and study day may be useful as image interpretation revision aids or to accompany formal methods of education.

A scoping review of educational programmes on artificial intelligence (AI) available to medical imaging staff.

INTRODUCTION: Medical imaging is arguably the most technologically advanced field in healthcare, encompassing a range of technologies which continually evolve as computing power and human knowledge expand. Artificial Intelligence (AI) is the next frontier which medical imaging is pioneering. The rapid development and implementation of AI has the potential to revolutionise healthcare, however, to do so, staff must be competent and confident in its application, hence AI readiness is an important precursor to AI adoption. Research to ascertain the best way to deliver this AI-enabled healthcare training is in its infancy. The aim of this scoping review is to compare existing studies which investigate and evaluate the efficacy of AI educational interventions for medical imaging staff. METHODS: Following the creation of a search strategy and keyword searches, screening was conducted to determine study eligibility. This consisted of a title and abstract scan, then subsequently a full-text review. Articles were included if they were empirical studies wherein an educational intervention on AI for medical imaging staff was created, delivered, and evaluated. RESULTS: Of the initial 1309 records returned, n = 5 (∼0.4 %) of studies met the eligibility criteria of the review. The curricula and delivery in each of the five studies shared similar aims and a 'flipped classroom' delivery was the most utilised method. However, the depth of content covered in the curricula of each varied and measured outcomes differed greatly. CONCLUSION: The findings of this review will provide insights into the evaluation of existing AI educational interventions, which will be valuable when planning AI education for healthcare staff. IMPLICATIONS FOR PRACTICE: This review highlights the need for standardised and comprehensive AI training programs for imaging staff.

Patient engagement with radiation therapists: Patient perspectives, challenges, and opportunities. A systematic review.

INTRODUCTION: Radiotherapy is a major component of cancer care and treatment is delivered almost exclusively by therapeutic radiographers/radiation therapists (RTTs). Numerous government and professional guidance publications have recommended a person-centred approach to healthcare through communication and collaboration between professionals, agencies, and users. With approximately half of patients undergoing radical radiotherapy experiencing some degree of anxiety and distress, RTTs are uniquely placed as frontline cancer professionals to engage with patients regarding their experience. This review seeks to map the available evidence of patient reported views of their experience of being treated by RTTs and any impact, this treatment had on the patient's frame of mind or perception of treatment. METHODS: In line with the principles of the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) systematic review methodology, a review of relevant literature was conducted. Electronic databases MEDLINE, PROQUEST, EMBASE and CINAHL were searched. RESULTS: Nine hundred and eighty-eight articles were identified. Twelve papers were included in the final review. CONCLUSION: Increased time with, and continuity of RTTs during treatment has a positive influence on patients' perspectives of RTTs. A positive patient perspective of their engagement with RTTs can be a strong predictor of overall satisfaction in radiotherapy. IMPLICATIONS FOR PRACTICE: RTTs should not underestimate the impact of their supportive role in guiding patients through treatment. A standardised method for integrating patients' experience and engagement with RTTs is lacking. Further RTT led research is required in this area.

The effect of a digital training tool to aid chest image interpretation: Hybridising eye tracking technology and a decision support tool.

INTRODUCTION: Eye tracking technology, checklists and search strategies have been demonstrated as useful aids in image interpretation. A training tool was developed, by the research team, which included these features. This study aimed to evaluate the effect of the training tool on participant image interpretation performance. METHODS: The study was carried out with reporting radiographers who had either commenced training in chest image interpretation (n = 12) or were trained in musculoskeletal image interpretation (n = 23) (total n = 35). Participants were allocated to a control or intervention group. Participants completed an initial assessment at recruitment and re-attended nine months later for a follow-up assessment. The intervention group were given unlimited access to a digital training tool. During assessments participants interpreted 20 chest images whilst using eye tracking technology (total of 1400 images were interpreted). A confidence level was obtained from participants on their diagnosis and a questionnaire, to obtain demographic data, was completed following the assessment. RESULTS: Improvements were seen in the confidence of intervention group participants (p < 0.05). False Positive (FP) scores decreased for both the control and intervention group (p < 0.05), this decrease was from 4.20 to 3.20 for the control group and from 5.87 to 3.27 for the intervention group. True Negative (TN) scores increased, from 5.13 to 6.73 for the intervention group (p < 0.05). Mean decision time decreased for both the control and intervention group. CONCLUSION: The tool led to positive effects on participant performance and could be a useful aid in chest image interpretation learning. IMPLICATIONS FOR PRACTICE: Improvements in performance were observed with a digital tool. The tool could improve image interpretation methods and training.

Digital training platform for interpreting radiographic images of the chest.

INTRODUCTION: Time delays and errors exist which lead to delays in patient care and misdiagnosis. Reporting clinicians follow guidance to form their own search strategy. However, little research has tested these training guides. With the use of eye tracking technology and expert input we developed a digital training platform to be used in chest image interpretation learning. METHODS: Two sections of a digital training platform were planned and developed; A) a search strategy training tool to assist reporters during their interpretation of images, and B) an educational tool to communicate the search strategies of expert viewers to trainees by using eye tracking technology. RESULTS: A digital training platform for use in chest image interpretation was created based on evidence within the literature, expert input and two search strategies previously used in clinical practice. Images and diagrams, aiding translation of the platform content, were incorporated where possible. The platform is structured to allow the chest image interpretation process to be clear, concise and methodical. CONCLUSION: A search strategy was incorporated within the tool to investigate its use, with the possibility that it could be recommended as an evidence based approach for use by reporting clinicians. Eye tracking, a checklist and voice recordings have been combined to form a multi-dimensional learning tool, which has never been used in chest image interpretation learning before. The training platform for use in chest image interpretation learning has been designed, created and digitised. Future work will establish the efficacy of the developed approaches.

Methods employed for chest radiograph interpretation education for radiographers: A systematic review of the literature.

OBJECTIVES: This systematic review aimed to determine the strength of evidence available in the literature on the effect of training to develop the skills required by radiographers to interpret plain radiography chest images. KEY FINDINGS: Thirteen articles feature within the review. Sample size varied from one reporting radiographer to 148 radiography students/experienced radiographers. The quality of the articles achieved a mean score of 7.5/10, indicating the evidence is strong and the quality of studies in this field is high. Investigative approaches included audit of participants' performance in clinical practice post formal training, evaluation of informal training and the impact of short feedback sessions on performance. CONCLUSION: All studies demonstrated positive attributions on user performance. Using a combination of training techniques can help maximise learning and accommodate those with different preferred learning types.

Assignment of Weight-Based Antibody Units for Four Additional Serotypes to a Human Antipneumococcal Standard Reference Serum, 007sp.

The pneumococcal enzyme-linked immunosorbent assay (ELISA) reference standard serum, lot 89SF, had been in use since 1990 and was replaced with a new reference standard serum, 007sp, in 2013. This serum was generated under an FDA-approved clinical protocol where 278 adult volunteers were immunized with the 23-valent unconjugated polysaccharide vaccine Pneumovax II and a unit of blood was obtained twice within 120 days following immunization. Pooled serum was prepared from the plasma, filled at 6 ml per vial, and lyophilized. Five independent laboratories participated in bridging the serotype-specific IgG assignments of 89SF to 007sp to establish equivalent reference values for 13 pneumococcal capsular serotypes (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F) using the WHO reference ELISA. A subsequent follow-up study established equivalent reference values for an additional seven serotypes (8, 10A, 11A, 12F, 15B, 22F, 33F). In this study, three laboratories assigned weight-based IgG concentrations in micrograms per milliliter of serum to 007sp for four additional serotypes: 2, 9N, 17F, and 20A. This study completes the assignment of serotypes for 89SF to 007sp. In addition, the IgG antibody assignments for a 12-member WHO quality control (QC) serum panel were extended to cover the four additional serotypes. Agreement was excellent, with a concordance correlation coefficient (rc ) of >0.996 when values from each laboratory were compared to the assigned values for the 12 WHO QC sera. The 007sp preparation has replaced 89SF as the pneumococcal reference standard. Sufficient quantities of 007sp are projected to be available for the next 25 years.

Determining performance characteristics of an NGS-based HLA typing method for clinical applications.

This study presents performance specifications of an in-house developed human leukocyte antigen (HLA) typing assay using next-generation sequencing (NGS) on the Illumina MiSeq platform. A total of 253 samples, previously characterized for HLA-A, -B, -C, -DRB1 and -DQB1 were included in this study, which were typed at high-resolution using a combination of Sanger sequencing, sequence-specific primer (SSP) and sequence-specific oligonucleotide probe (SSOP) technologies and recorded at the two-field level. Samples were selected with alleles that cover a high percentage of HLA specificities in each of five different race/ethnic groups: European, African-American, Asian Pacific Islander, Hispanic and Native American. Sequencing data were analyzed by two software programs, Omixon's target and GenDx's NGSengine. A number of metrics including allele balance, sensitivity, specificity, precision, accuracy and remaining ambiguity were assessed. Data analyzed by the two software systems are shown independently. The majority of alleles were identical in the exonic sequences (third field) with both programs for HLA-A, -B, -C and -DQB1 in 97.7% of allele determinations. Among the remaining discrepant genotype calls at least one of the analysis programs agreed with the reference typing. Upon additional manual analysis 100% of the 2530 alleles were concordant with the reference HLA genotypes; the remaining ambiguities did not exceed 0.8%. The results demonstrate the feasibility and significant benefit of HLA typing by NGS as this technology is highly accurate, eliminates virtually all ambiguities, provides complete sequencing information for the length of the HLA gene and forms the basis for utilizing a single methodology for HLA typing in the immunogenetics labs.

Assignment of Weight-Based Antibody Units for Seven Additional Serotypes to a Human Pneumococcal Standard Reference Serum, 007sp.

The pneumococcal enzyme-linked immunosorbent assay (ELISA) reference standard serum, lot 89SF, has been in use since 1990 and was replaced in 2013 with a new reference standard, 007sp, that is projected to be available for the next 25 years. 007sp was generated under an FDA-approved clinical protocol; 278 adult volunteers were immunized with the 23-valent unconjugated polysaccharide vaccine Pneumovax II, and a unit of blood was obtained twice from each immunized subject within 120 days following immunization. Pooled serum was prepared from the plasma of 262 subjects, filled at 6 ml per vial, and lyophilized. Five independent laboratories participated in bridging the serotype-specific IgG assignments for 89SF to the new reference standard, 007sp, to establish equivalent reference values for 13 pneumococcal capsular serotypes (1,3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F) by using the WHO reference ELISA. In a second study involving three laboratories, a similar protocol was used to assign weight-based IgG concentrations in micrograms per ml to 007sp of seven serotypes (8, 10A, 11A, 12F, 15B, 22F, and 33F) also present in the 23-valent pneumococcal unconjugated polysaccharide vaccine. In addition, the IgG assignments for a 12-member WHO quality control (QC) serum panel were also extended to cover these seven serotypes. Agreement was excellent, with a concordance correlation coefficient (r(c)) of >0.996 when each laboratory was compared to the assigned values for the 12 WHO QC serum samples. There are four remaining pneumococcal serotypes (2, 9N, 17F, and 20) found in Pneumovax II for which IgG assignments exist for 89SF and remain to be bridged.

Glyco-engineered anti-EGFR mAb elicits ADCC by NK cells from colorectal cancer patients irrespective of chemotherapy.

BACKGROUND: The epidermal growth factor receptor (EGFR) is overexpressed in colorectal cancer (CRC), and is correlated with poor prognosis, making it an attractive target for monoclonal antibody (mAb) therapy. A component of the therapeutic efficacy of IgG1 mAbs is their stimulation of antibody-dependent cellular cytotoxicity (ADCC) by natural killer (NK) cells bearing the CD16 receptor. As NK cells are functionally impaired in cancer patients and may be further compromised upon chemotherapy, it is crucial to assess whether immunotherapeutic strategies aimed at further enhancing ADCC are viable. METHODS: CRC patients before, during and after chemotherapy were immunophenotyped by flow cytometry for major white blood cell populations. ADCC-independent NK cell functionality was assessed in cytotoxicity assays against K562 cells. ADCC-dependent killing of EGFR(+) A431 cancer cells by NK cells was measured with a degranulation assay where ADCC was induced by GA201, an anti-EGFR mAb glyco-engineered to enhance ADCC. RESULTS: Here, we confirm the observation that NK cells in cancer patients are dysfunctional. However, GA201 was able to induce robust NK cell-dependent cytotoxicity in CRC patient NK cells, effectively overcoming their impairment. CONCLUSIONS: These findings support the evaluation of the therapeutic potential of GA201 in combination with chemotherapy in CRC patients.

Early infections after autologous hematopoietic stem cell transplantation in children and adolescents: the St. Jude experience.

INTRODUCTION: Advances in autologous hematopoietic stem cell transplantation (HSCT) over the past 20 years may have had an impact on the morbidity and mortality associated with infections post transplant. PATIENTS AND METHODS: We sought to retrospectively analyze the epidemiology of the first episode of bacterial, fungal, viral, or parasitic infections 0-30 days post transplant in a cohort of 320 children and adolescents who underwent autologous HSCT in a single institution, between 1990 and 2009 for solid tumors or lymphoma, and in 65 children transplanted for acute leukemia during the same period. RESULTS: Infections occurred in 66 (21%) patients with solid tumors or lymphoma. Bacterial infections occurred in 33 (10%) including bacteremia in 23 (7%), and viral infections in 34 (11%) patients. Gram-positive bacterial infections were more prevalent than gram-negative bacterial infections (P = 0.03). Infections caused by fungal or parasitic pathogens were uncommon. The decade when transplant was performed (1990-1999 vs. 2000-2009) had no impact on the incidence of bacterial (P = 0.41) or viral (P = 0.47) infection. Between 1990 and 1999, a total of 60 (92%) children were transplanted for leukemia, and 5 (8%) in the 2000-2009 period (P < 0.0001). Infections occurred in 32 (49%) patients. Bacterial (P = 0.004), candidal (P = 0.003), and herpes simplex viral (P = 0.03) infections were more common in patients transplanted for leukemia. In patients transplanted for leukemia, 3 deaths occurred attributed to infection, all before 2000. CONCLUSION: Changes in epidemiology of infection are likely a result of decline in autologous transplantation for childhood leukemia in the recent era. Autologous transplantation for solid tumors or lymphoma was not associated with mortality from early infections at our institution.

Directed blood donor program decreases donor exposure for children with sickle cell disease requiring chronic transfusion.

In children with sickle cell disease (SCD), primary and secondary prevention of strokes require indefinite regular blood transfusion therapy. The risks associated with repeated transfusions include alloimmunization and increased donor exposure. The Charles Drew Program is a directed blood donor program designed to lower donor exposure, decreasing the associated complications of transfusion; however, no evidence exists demonstrating the magnitude of the benefit to the recipient. Further, the use of extended red blood cell (RBC) antigen matching for C, E, and K has been well documented in a clinical trial setting but not extensively evaluated in a standard care setting. The goal of this study is to assess the effectiveness in reducing alloimmunization when matching for C, E, and K and the magnitude of the decrease in donor exposure in a directed blood donor program. The rate of alloimmunization and reduction of donor exposure were determined during the course of 1 year in a cohort of children with SCD who received regular directed donor blood transfusions. A total of 24 recipients were in the program, 16 females and 8 males, 4 to 20 years of age. During 2008, alloimmunization was 0 percent and donor exposure was reduced by 20 percent, compared with usual care. Extended RBC antigen matching has the same benefit as in a clinical trial setting for patients with SCD receiving blood transfusion therapy. Despite significant effort, we only achieved a modest decrease in donor exposure and cannot determine the immediate benefit of a directed blood donor program.

Survival and prognostic indicators for cycad intoxication in dogs.

BACKGROUND: Cycad palms are commonly used in landscaping and ingestion by dogs can cause disease or death. OBJECTIVES: Determine the morbidity and case fatality of cycad palm toxicosis in dogs from Louisiana, and examine putative prognostic factors. ANIMALS: Thirty-four client-owned dogs with confirmed cycad palm toxicosis between 2003 and 2010. METHODS: Retrospective cohort study. Search of all medical records for animals with cycad palm toxicosis. RESULTS: Seventeen of 34 (50%) dogs died or were euthanized as a direct consequence of cycad intoxication. There were no differences in presenting signs and physical examination findings between survivors and nonsurvivors. Nonsurvivors had higher serum alanine transaminase activity (median 196 U/L; range 16-4,123 versus 113.5; 48-1,530) and total bilirubin concentration (0.5 mg/dL; 0.1-6.2 versus 0.25; 0-1.7) upon presentation, and their initial serum concentrations of albumin (2.9 g/dL; 1.4-4.1 versus 3.3; 2.2-3.9) were lower than those of survivors. Nadir serum albumin concentration was also lower in nonsurvivors (1.9; 1.4-3.7 versus 3.2; 1.8-3.5). A higher proportion of nonsurvivors had prolonged coagulation times, prothrombin time. and partial thromboplastin time. In a multivariate model, administration of charcoal at initial presentation was associated with longer survival (heart rate [HR] 0.019, 95% CI 0.001-0.644), while high serum aspartate aminotransferase activity was a negative prognostic factor (HR 118.2, 95% CI 2.89-4,826). CONCLUSIONS AND CLINICAL IMPORTANCE: Cycad intoxication is associated with a higher case fatality than previously published. Several laboratory parameters might help differentiating potential nonsurvivors from survivors. Administration of charcoal as part of the emergency treatment appears to have a protective effect.

mRNA induces RANTES production in trophoblast cells via TLR3 only when delivered intracellularly using lipid membrane encapsulation.

BACKGROUND: Trophoblasts express Toll-like receptor 3 (TLR3). The artificial TLR3 ligand, PolyI:C, induces an inflammatory response in trophoblasts but an endogenous ligand has not been identified. Notably, inflammatory disorders of pregnancy are associated with increased circulating placenta-derived mRNA. Endogenous degraded, uncapped mRNA is recognized by TLR3 in other cell lines. OBJECTIVE: We tested the hypothesis that plasma-derived mRNA induces an inflammatory response in a trophoblast cell line via TLR3. METHODS: Experiments were performed in the human first trimester extravillous trophoblast cell line HTR-8/SV neo. Plasma-derived mRNA was amplified using modified template switching and final in vitro transcription. We compared free mRNA (which favors cell surface interaction) to liposomally encapsulated mRNA (which favors intracellular mRNA delivery). We tested for the specific requirement of TLR3 signaling using siRNA. We tested for involvement of the canonical signaling pathway downstream of TLR3 by measuring NF-κB and IFN regulatory factor transcriptional activity using firefly-luciferase constructs. RESULTS: Free mRNA did not induce RANTES production. In contrast, liposomal mRNA resulted in marked induction of RANTES production (non-stimulated control 3.4 ± 0.6 pg/mL, liposomal mRNA 169.7 ± 26.2 pg/mL, p < 0.001), and this RANTES production was abolished by siRNA for TLR3. Downstream of TLR3, liposomal mRNA-induced dose-response NF-κB and IFN regulatory factor transcriptional activity, and IFN beta production. CONCLUSION: Plasma-derived 5' uncapped mRNA delivered intracellularly signals to induce NF-κB activation and increase RANTES production via TLR3.

Next-generation sequencing: the solution for high-resolution, unambiguous human leukocyte antigen typing.

Human leukocyte antigen (HLA) typing has been a challenge for more than 50 years. Current methods (Sanger sequencing, sequence-specific primers [SSP], sequence-specific oligonucleotide probes [SSOP]) continue to generate ambiguities that are time-consuming and expensive to resolve. However, next-generation sequencing (NGS) overcomes ambiguity through the combination of clonal amplification, which provides on-phase sequence and a high level of parallelism, whereby millions of sequencing reads are produced enabling an expansion of the HLA regions sequenced. We explored HLA typing using NGS through a three-step process. First, HLA-A, -B, -C, -DRB1, and -DQB1 were amplified with long-range PCR. Subsequently, amplicons were sequenced using the 454 GS-FLX platform. Finally, sequencing data were analyzed with Assign-NG software. In a single experiment, four individual samples and two mixtures were sequenced producing >75 Mb of sequence from >300,000 individual sequence reads (average length, 244 b). The reads were aligned and covered 100% of the regions amplified. Allele assignment was 100% concordant with the known HLA alleles of our samples. Our results suggest this method can be a useful tool for complete genomic characterization of new HLA alleles and for completion of sequence for existing, partially sequenced alleles. NGS can provide complete, unambiguous, high-resolution HLA typing; however, further evaluation is needed to explore the feasibility of its routine use.

Application of high rate, high temperature anaerobic digestion to fungal thermozyme hydrolysates from carbohydrate wastes.

The objective of this study was to examine the feasibility of using a two-step, fully biological and sustainable strategy for the treatment of carbohydrate rich wastes. The primary step in this strategy involves the application of thermostable enzymes produced by the thermophilic, aerobic fungus, Talaromyces emersonii, to carbohydrate wastes producing a liquid hydrolysate discharged at elevated temperatures. To assess the potential of thermophilic treatment of this hydrolysate, a comparative study of thermophilic and mesophilic digestion of four sugar rich thermozyme hydrolysate waste streams was conducted by operating two high rate upflow anaerobic hybrid reactors (UAHR) at 37 degrees C (R1) and 55 degrees C (R2). The operational performance of both reactors was monitored from start-up by assessing COD removal efficiencies, volatile fatty acid (VFA) discharge and % methane of the biogas produced. Rapid start-up of both R1 and R2 was achieved on an influent composed of the typical sugar components of the organic fraction of municipal solid waste (OFMSW). Both reactors were subsequently challenged in terms of volumetric loading rate (VLR) and it was found that a VLR of 9 gCOD l(-1)d(-1) at a hydraulic retention time (HRT) of 1 day severely affected the thermophilic reactor with instability characterised by a build up of volatile fatty acid (VFA) intermediates in the effluent. The influent to both reactors was changed to a simple glucose and sucrose-based influent supplied at a VLR of 4.5 gCOD l(-1)d(-1) and HRT of 2 days prior to the introduction of thermozyme hydrolysates. Four unique thermozyme hydrolysates were subsequently supplied to the reactors, each for a period of 10 HRTs. The applied hydrolysates were derived from apple pulp, bread, carob powder and cardboard, all of which were successfully and comparably converted by both reactors. The % total carbohydrate removal by both reactors was monitored during the application of the sugar rich thermozyme hydrolysates. This approach offers a sustainable technology for the treatment of carbohydrate rich wastes and highlights the potential of these wastes as substrates for the generation of second-generation biofuels.

Stability, continence and breathing: the role of fascia following pregnancy and delivery.

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during pregnancy and 20-25% in the early postpartum period. Most women become pain free in the first 12 weeks after delivery, however, 5-7% do not. In a large postpartum study of prevalence for urinary incontinence (UI) [Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C., 2002. Obstetric practice and urinary incontinence 5-7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284-300] found that 45% of women experienced UI at 7 years postpartum and that 27% who were initially incontinent in the early postpartum period regained continence, while 31% who were continent became incontinent. It is apparent that for some women, something happens during pregnancy and delivery that impacts the function of the abdominal canister either immediately, or over time. Current evidence suggests that the muscles and fascia of the lumbopelvic region play a significant role in musculoskeletal function as well as continence and respiration. The combined prevalence of lumbopelvic pain, incontinence and breathing disorders is slowly being understood. It is also clear that synergistic function of all trunk muscles is required for loads to be transferred effectively through the lumbopelvic region during multiple tasks of varying load, predictability and perceived threat. Optimal strategies for transferring loads will balance control of movement while maintaining optimal joint axes, maintain sufficient intra-abdominal pressure without compromising the organs (preserve continence, prevent prolapse or herniation) and support efficient respiration. Non-optimal strategies for posture, movement and/or breathing create failed load transfer which can lead to pain, incontinence and/or breathing disorders. Individual or combined impairments in multiple systems including the articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or multiple tasks. Biomechanical aspects of the myofascial piece of the clinical puzzle as it pertains to the abdominal canister during pregnancy and delivery, in particular trauma to the linea alba and endopelvic fascia and/or the consequence of postpartum non-optimal strategies for load transfer, is the focus of the first two parts of this paper. A possible physiological explanation for fascial changes secondary to altered breathing behaviour during pregnancy is presented in the third part. A case study will be presented at the end of this paper to illustrate the clinical reasoning necessary to discern whether conservative treatment or surgery is necessary for restoration of function of the abdominal canister in a woman with postpartum diastasis rectus abdominis (DRA).